| (a) A LIDDA must assign a habilitation coordinator
to each designated resident within two business days after a PE is
completed if the PE is positive for ID or DD.
(1) The habilitation coordinator must attend the initial
IDT and provide habilitation coordination while the designated resident
is residing in the NF.
(2) A designated resident may refuse habilitation coordination.
(b) Unless a designated resident has refused habilitation
coordination, the assigned habilitation coordinator must:
(1) assess and reassess quarterly, and as needed, the
designated resident's habilitative service needs by gathering information
from the designated resident and other appropriate sources, such as
the LAR, family members, social workers, and service providers, to
determine the designated resident's habilitative needs and preferences
and the specialized services that will address those needs and preferences;
(2) develop and revise, as needed, an individualized
HSP in accordance with HHSC's rules and IDD PASRR Handbook, and using
HHSC forms;
(3) assist the designated resident to access needed
specialized services agreed upon in an IDT or SPT meeting, including:
(A) monitoring to determine if a specialized service
agreed upon in an IDT or SPT meeting is requested within required
timeframes in accordance with the IDD PASRR Handbook or documenting
delays and the habilitation coordinator's follow-up activities; and
(B) ensuring the delivery of all specialized services
agreed upon in an IDT or SPT meeting or documenting delays and the
habilitation coordinator's follow-up activities;
(4) coordinate other habilitative programs and services
that can address needs and achieve outcomes identified in the HSP;
(5) facilitate the coordination of the designated resident's
HSP and NF comprehensive care plan, including ensuring the HSP is
shared with members of the SPT within 10 calendar days after the HSP
is updated or renewed;
(6) monitor and provide follow-up activities that consist
of:
(A) monitoring the initiation and delivery of all specialized
services agreed upon in an IDT or SPT meeting and following up when
delays occur;
(B) monitoring the designated resident's and LAR's
satisfaction with all specialized services; and
(C) determining the designated resident's progress
or lack of progress toward achieving goals and outcomes identified
in the HSP from the designated resident's and LAR's perspectives;
(7) meet with the designated resident to provide habilitation
coordination:
(A) at least monthly if the designated resident is
receiving a specialized service in addition to habilitation coordination;
and
(i) meet in person at least quarterly or more frequently
as determined by the SPT using the findings of the HHSC Habilitative
Assessment form; and
(ii) subject to subsection (d) of this section, meet
via audio-visual communication in a month when a meeting is not conducted
in person; or
(B) at least quarterly in person, if the designated
resident is receiving only habilitation coordination, unless the designated
resident or the designated resident's LAR requests more frequent meetings;
(8) convene and facilitate an SPT meeting:
(A) at least quarterly; and
(B) between quarterly SPT meetings if:
(i) there is a change in the designated resident's
service needs or medical condition; or
(ii) requested by the designated resident or LAR;
(9) coordinate with the NF in accessing medical, social,
educational, and other appropriate services and supports that will
help the designated resident achieve a quality of life acceptable
to the designated resident and LAR on the resident's behalf;
(10) initially and annually thereafter:
(A) provide the designated resident and LAR an oral
and written explanation of the designated resident's rights in accordance
with the IDD PASRR Handbook; and
(B) inform the designated resident and LAR both orally
and in writing of all the services available and requirements pertaining
to the designated resident's participation;
(11) for a designated resident who has a guardian,
determine at least annually if the letters of guardianship are current;
and
(12) if appropriate, for a designated resident who
does not have a guardian, ensure the SPT discusses whether the designated
resident would benefit from a less restrictive alternative to guardianship
or from guardianship and make appropriate referrals.
(c) Regardless of whether the designated resident is
receiving or has refused habilitation coordination, the habilitation
coordinator must:
(1) address community living options with the designated
resident and LAR by:
(A) offering the educational opportunities and informational
activities about community living options that are periodically scheduled
by the LIDDA;
(B) providing information about the range of community
living services, supports, and alternatives, identifying the services
and supports the designated resident will need to live in the community,
and identifying and addressing barriers to community living in accordance
with HHSC's IDD PASRR Handbook and using HHSC materials at the following
times:
(i) six months after the initial presentation of community
living options during the PE described in §303.302(a)(2)(B)(i)
of this Chapter (relating to LIDDA, LMHA, and LBHA Responsibilities
Related to the PASRR Process) and at least every six months thereafter;
(ii) when requested by the designated resident or LAR;
(iii) when the habilitation coordinator is notified
or becomes aware that the designated resident, or the LAR on the designated
resident's behalf, is interested in speaking with someone about transitioning
to the community; and
(iv) when notified by HHSC that the designated resident's
response in Section Q of the MDS Assessment indicates the resident
is interested in speaking with someone about transitioning to the
community; and
(C) arranging visits to community providers and addressing
concerns about community living; and
(2) annually assess the designated resident's habilitative
service needs by gathering information from the designated resident
and other appropriate sources, such as the LAR, family members, social
workers, and service providers, to determine the designated resident's
habilitative needs and preferences.
(d) Before the habilitation coordinator conducts the
meeting described in subsection (b)(7)(A)(ii) of this section via
audio-visual communication, the habilitation coordinator must:
(1) obtain the written informed consent of the designated
resident or LAR; or
(2) obtain the designated resident's or LAR's oral
consent and document the oral consent in the designated resident's
record.
(e) If the habilitation coordinator does not obtain
the written or oral consent required by subsection (d) of this section,
the habilitation coordinator must document the designated resident's
or LAR's refusal in the designated resident's record.
|
| Source Note: The provisions of this §303.601 adopted to be effective July 7, 2019, 44 TexReg 3265; amended to be effective September 1, 2021, 46 TexReg 5419; amended to be effective April 15, 2024, 49 TexReg 2287 |
